Hemorrhoidal Dearterialization Research Articles

Conventional excisional haemorrhoidectomy versus transanal haemorrhoidal dearterialization for haemorrhoids - a systematic review and meta-analysis.

Introduction Although effective, conventional excisional haemorrhoidectomy (CEH) may be associated with significant postoperative pain. Novel techniques such as transanal haemorrhoidal dearterialization (THD) are suggested to reduce pain, but may result in higher recurrence rates. We aimed to compare short and long-term outcomes of CEH and THD in the present meta-analysis. Methods A PRISMA-compliant meta-analysis was performed, searching PubMed, EMBASE and CENTRAL databases for randomized controlled trials (RCTs) from 1995 until December 2022. The primary objective was recurrence. Secondary objectives included complication rates, length of stay (LOS), operative time and time to return to baseline. Random-effects models were used to calculate pooled effect size estimates. Subgroup analysis was also performed. Results 6 RCTs encompassing 465 patients were captured. There were 142 (59%) males in the CEH group and 129 (54%) in the THD group.. On random effects analysis, THD had a higher recurrence rate (OR = 2.76, 95% CI = 1.03 to 7.38, p = 0.04) albeit a shorter return to baseline comparative to CEH (MD = -14.05 days, 95% CI = -20.38 to -7.72, p < 0.0001). There were no differences in bleeding (p = 0.12), urinary retention (p = 0.97), incontinence (p = 0.41), anal stenosis (p = 0.19), thrombosed residual haemorrhoids (p = 0.16), operating time (p = 0.19) or LOS (p = 0.22). Results remained similar on subgroup analysis. Conclusions CEH is associated with lower recurrence rates and no difference in complication rate to THD, although patients take longer to return to baseline function postoperatively.

Anatomy of the terminal branches of the superior rectal artery during selective doppler controlled dearterialization of the hemorrhoidal nodes (HAL-RAR)

Background: To date, there is no single standard for conducting HAL-RAR operations. The constant discussion raises the question of the number of terminal branches of the superior rectal artery, which must be ligated in the submucosal layer of the rectum in order to provide the adequate dearterialization of hemorrhoids. Aim: To study the anatomy of the branches of the superior rectal artery and to develop recommendations for the optimal ligation of the terminal branches of the superior rectal artery. Methods: 150 protocols of the previous operations have been studied. In order to further objectify our results, the results of radiation diagnostics (CT and MRI) were revised for 100 patients without pathological changes of the rectum and anal canal to study the variant anatomy of the superior rectal artery and its terminal branches in the rectal wall. Results: In 148 patients, 6 terminal branches were identified, in 2 (1.333%) patients, 5 branches were found. 100 cases without pathological changes were also analyzed (60 MRI and 40 CT scans). In all the cases, 6 terminal branches of the superior rectal artery were determined, located at 1, 3, 5, 7, 9 and 11 o'clock positions of the conventional dial. At the same time, a large number of identified anatomical options for the branching of the VPA and the method for reaching the rectal wall should be noted, which we used as a basis to propose a classification. Conclusion: In the vast majority of cases, there are 6 terminal branches of the superior rectal artery, located in the lower ampulla of the rectum at approximately 1, 3, 5, 7, 9 and 11 hours of the conventional dial. A number of variants of the vascular anatomy of the proximal branches are possible, but 6 distal branches are involved in the direct blood supply of the hemorrhoids. When performing selective Doppler-controlled dearterialization of hemorrhoids, it is expedient to ligate 6 arterial vessels.

The learning curve for transanal hemorrhoidal dearterialization with mucopexy. Experience of 459 cases

Aim: to evaluate learning curve for transanal hemorrhoidal dearterialization (THD) with mucopexy for chronic hemorrhoids II-IV stage.Patients and Methods: the THD was performed by one surgeon in 459 patients under local anesthesia in 2013- 2021. Patients were aged 45 (37;54) years, 355 (77.3%) — males. Stage II was diagnosed in 85 (18.5%) cases, stage II-III — in 47 (10.2%), stage III — in 296 (64.5%), stage III-IV and IV — in 27 (5.9%) and 4 (0.9%) cases. Regression and CUSUM analysis were used to construct the learning curve. The operation time, postoperative morbidity and recurrence rate were assessed.Results: the operation time was 25 (25;32.5) minutes, it was achieved on 210 cases. The postoperative complications occurred in 7 (1.5%) cases and were significantly often in stage III-IV and IV — 3 (9.7%) cases (p = 0.001). Recurrence was showed in 29 (6.3%) cases after 1 year of follow-up. The CUSUM function graph showed that with the experience level, a 2-fold decrease in the morbidity rate and recurrence rate was achieved after 24 and 28 procedures, respectively. When experience is achieved, the morbidity rate was low regardless of the disease stage. Despite the experience obtained, in patients operated in the 3rd and 4th quartiles, the recurrences occurred in 10 (7.7%) and 9 (8.8%) patients, respectively.Conclusion: the indicator of experience obtained is the decrease of operation time and post-op morbidity. The experience level dies not affect recurrence rate in stages III-IV due to limitations of the technique.

Haemorrhoidal artery distribution in patients with grade III and IV haemorrhoids treated with artery ligation and rectoanal repair. Assessment of Doppler guidance

IntroductionWhile haemorrhoidal dearterialization and mucopexy are accepted as a valid alternative to haemorrhoidectomy, differences exist regarding the fixed or variable location of the arteries to be ligated. Our aim was to shed light on this issue of arterial distribution in candidates for surgery. MethodsThe study included consecutive patients diagnosed with Goligher grade III and IV haemorrhoids, who had undergone Doppler-guided haemorrhoidal artery ligation (DG-HAL) and rectoanal repair (RAR) at 2 medical centres in Spain. The main objective was to evaluate the number and 12-h clock locations of arterial ligatures necessary to achieve Doppler silence. ResultsIn total, 146 patients were included: 111 (76%) men, and 35 (24%) women. Average age was 54 years (21–84). Grade III and grade IV haemorrhoids were diagnosed in 106 (72.6%) and 40 (27.4%) patients, respectively. The average number of ligatures per patient was 7 (range 2–12).Ligature percentages greater than 60% occurred at clock positions 7, 11, 10, 12, 9, and 1. The average number of mucopexies per patient was 3 (range 1–4). The most frequent mucopexy locations were the left posterior, right posterior, and right anterior octants. ConclusionsWhile the greatest frequency of arterial ligatures occurred in odd-numbered clock positions, non-negligible percentages occurred in even-numbered clock positions, which, in our opinion, makes the use of Doppler necessary, given that arterial distribution is not the same in all patients. We also noted that more ligatures and mucopexies were needed on the right half of the rectal circumference than on the left side, suggesting greater right-side vascularization.

090 Transarterial Haemorrhoidal Dearterialization Versus Open Haemorrhoidectomy for Symptomatic Haemorrhoids- a Meta-Analysis of Randomized Controlled Trials

Abstract Although effective, open haemorrhoidectomy (OH) is associated with significant postoperative pain. Novel non-excisional techniques such as transarterial haemorrhoidal dearterialization (THD) are increasingly advocated due to a lower incidence of pain and complications. We aimed to compare short and long-term outcomes of THD and OH in the present meta-analysis. A PRISMA-compliant systematic review and meta-analysis was performed including randomised controlled trials (RCTs) from inception until June 2022. The primary objective was recurrence, whilst secondary objectives included complication rates, mean length of stay (LOS), operative time and time to return to baseline. Random-effects models were used to calculate pooled effect size estimates. A p-value < 0.05 was considered statistically significant. 6 RCTs encompassing 474 patients were captured. There were 129 (54%) males in the THD group and 142 (59%) in the OH group. On random effects analysis, OH had a lower recurrence rate (OR = 2.76, p = 0.04) whereas THD was associated with a quicker return to baseline (MD = -14.05 days, p < 0.0001). There were no differences in bleeding (OR = 0.58,p = 0.09), urinary retention (OR = 1.01, p = 0.99), incontinence (OR = 0.49, p = 0.41), anal stenosis (OR = 0.14, p = 0.19), number of patients with chronic pain (OR = 1.30, p = 0.40), operating time (MD = 11.79 mins, p = 0.20) or LOS (MD = -0.23 days, p = 0.22). THD is a safe technique that affords a quicker return to baseline post procedure but is associated with a higher recurrence rate compared to OH.

The evolution of hemorrhoids publications during 1980-2021: a global and medical view with bibliometric analysis

Aims: Hemorrhoids is a common anorectal disorder and significantly affects quality of life. Although the number of global studies on hemorrhoids has increased in recent years, there is still no bibliometric study in the literature. In this study, it aimed that analyzing the scientific articles published on hemorrhoids holistically. 
 Methods: The articles published between 1980 and 2021 were analyzed using bibliometric and statistical methods on hemorrhoids. Network visualization maps were used to identify trending topics and international collaborations. Spearman’s correlation coefficient was used for correlation studies. The Exponential Triple Smoothing estimator was used to estimate the number of articles expected to be published in the coming years. 
 Results: A total of 3203 publications were found. 1863 (58.1%) of these publications were articles. The most active author is Gupta PJ. (n=26). The first 2 journals that published the most articles were Diseases of the Colon & Rectum (n=228) and Colorectal Disease (n=82). Singapore General Hospital (n=35) and University of Rome La Sapienza (n=19) were the 2 most active institutions. According to the average number of citations per article, the top 2 most influential journals were British Journal of Surgery and American Journal of Gastroenterology. 
 Conclusion: In this comprehensive study on hemorrhoids, a statistical analysis of 1863 articles was shared. It was determined that the trend topics in hemorrhoid researches were THD, mucopexy, transanal hemorrhoidal dearterialization, colorectal surgery, embolization, constipation, risk factors, Milligan-Morgan, classification, recurrence and randomized controlled trial. This article can be a useful resource for scientists and clinicians in terms of the global output of hemorrhoids yesterday, today and tomorrow.

Simultaneous treatment for anal fissure and hemorrhoids

When using surgical approach to treatment for combined anal fissure and hemorrhoids doctor always faces the question of whether to divide the procedure into two sequential stages or to perform a simultaneous surgical intervention, and in which cases one or the other should be done. Purpose - to improve the results of treatment for patients with anal fissure in combination with chronic hemorrhoids by combining fissurectomy with transanal hemorrhoidal dearterialization (THD). Materials and methods. 177 patients with combination of anal fissure and hemorrhoids were studied. The Group I (GI) - fissure excision and hemorrhoidectomy, 60 patients. The Group II (GII) - anal fissure excision without surgery for hemorrhoids, 60 patients. The Group III (GIII) - proposed method used, 57 patients. Laser Doppler flowmetry was performed to assess blood flow intensity in fissure area. The assessment of treatment outcomes in patients was based on the following criteria: pain intensity, urinary retention in early postoperative period, postoperative wound suppuration, disease recurrence, iatrogenic incontinence, duration of postoperative hospital stay. Qualitative parameters are presented as the absolute number of cases (n) and their percentage (%). Comparison of these parameters between groups was performed using the Pearson’s χ2 test and the Fisher’s exact test. Statistical analysis was conducted by STATA 12.1 statistical package. Results. Pain intensity: GI - 8±1, GII - 6±2, GIII - 4±1. Urinary retention: GI - 19 (31.6%), GII - 8 (13%), GIII - 6 (10.5%). Wound suppuration: GI - 5 (8.3%), GII - 1 (1.7%), GIII - 1 (1.7%). Hospital stay (days): GI - 6±1.2, GII - 4±1.3, GIII - 3±1.1. Fissure recurrences: GI - 5 (8.3%), GII - 2 (3.3%), GIII - 1 (1.7%). Hemorrhoid recurrence: GI - 6 (10%), GIII - 2 (3.5%). Iatrogenic incontinence: GI - 4 (6.7%), GII - 1 (1.7%), GIII - 0. Significant decrease in relative risk of complications (by 88%) in GIII compared with GI - OR=0.12 (0.04-0.29), p=0.0001, and a tendency to reduction of complication risk by 15% compared with GII - OR=0.85 (0.29-2.4), p=0.734 was observed. Blood flow intensity (flowmetry results) in GII and GIII was comparable. Conclusions. Simultaneous anal fissure excision and THD can improve treatment outcomes. This method does not impair blood flow in the area of anal fissure. Proposed method is both radical and minimally invasive. The research was carried out in accordance with the principles of the Helsinki Declaration. The study protocol was approved by the Local Ethics Committee of all participating institutions. The informed consent of the patient was obtained for conducting the studies. No conflict of interests was declared by the authors.

Results of sclerotherapy and mucopexy with haemorrhoidal dearterialization in II and III degree haemorrhoids. A 4 years' single centre experience.

Haemorrhoidal disease (HD) affects a considerable portion of the adult population. The aim of this study is to confirm the safety and efficacy of the treatments and to report the long-term outcomes of Sclerotherapy (ST) and Mucopexy and Haemorrhoidal Dearterialization (MHD) performed over the last 4 years in a single tertiary centre. The secondary outcome is to evaluate the usefulness of both techniques and to demonstrate how those can be associated as a bridge to surgery. Patients affected by second-third-degree haemorrhoids and undergoing ST or non-Doppler guided MHD between 2018 and 2021 were enrolled. Safety and efficacy, recurrence rate, Haemorrhoid Severity Score (HSS) and pain resulting from both techniques were evaluated. Out of 259 patients, 150 underwent ST. Further, 122 (81.3%) patients were male and 28 (18.7%) were female. The mean age was 50.8 (range 34-68) years. Most of the patients (103, 68.6%) were affected by second-degree HD, while 47 (31.4%) were affected by third-degree HD. The overall success rate was 83.3%. The median pre-operative HSS score was 3 (IQR 0-4, p = 0.04) and at 2 year the median HSS was 0 (IQR 0-1, p = 0.03). No intraoperative complications and no drug-related side effects occurred. The mean follow-up for ST was 2 years (range 1-4; SD ±0.88). MHD was performed on 109 patients. In detail, 80 patients (73.4%) were male while 29 patients (26.6%) were female. The mean age in this group was 51.3 (range 31-69). Further, 72 patients (66.1%) were affected by third-degree HD and 37 (33.9%) by second-degree HD. The median HSS score was 9 (IQR 8-10, p = 0.001) preoperatively two years after treatment was 0 (IQR 0-1, p = 0.004). Major complications occurred in three patients (2.75%). The overall success rate was 93.5% (second degree 89.2% vs. third degree 95.8%). The mean follow-up for MHD was 2 years (range 1-4; SD ±0.68). The results confirm the usefulness of those techniques, which can be considered safe and easily repeatable procedures, with a low recurrence rate after 2 years of median follow-up.

O132 Preliminary results of radiofrequency ablation for haemorrhoidal disease at a district general hospital

Abstract Introduction Haemorrhoidal disease (HD) is a common perianal condition. There is still limited data on the role of minimally invasive surgery for HD. The aim of our study was to report the outcome of radiofrequency ablation of haemorrhoids under local anaesthetic (RAFAELO) at our institution. Methods 23 patients who had a day-case RAFAELO procedure under local anaesthesia without sedation by a single surgeon from March to October 2022 were retrospectively reviewed. We analysed patients’ demographics, haemorrhoid severity score (HSS), the health's condition scale in EQ-5D-5L questionnaire, and recurrence rate. Results The mean age of patients was 50 years (SD 14). 65% were male whereas 35% were female. Majority of haemorrhoids (48%) were Grade 3A. Most of the cases had previous procedures such as rubber band ligation (57%) and hemorrhoidal dearterialization (9%). Only 34% had no prior hemorrhoidal surgery. The mean HSS score significantly improved from 13.2 (SD 4.9) to 4 (SD 2.2) with p < 0.001 postoperatively. The health's condition scale became significantly lower from 64 (SD 23.6) to 23.9 (SD 14.6) with p < 0.001. The median length of follow up was 2 months (range 1-5 months). There was no acute postprocedural complication but there was a recurrence rate of 13% requiring further procedures. Conclusion This study supports previous findings that RAFAELO is a safe and effective procedure for HD. It also highlights that it can be performed in the out-patient setting safely. However, further studies with larger samples, longer follow-up and comparison with other procedures are suggested.

Hemorrhoid laser dearterialization: systematic review and meta-analysis.

Hemorrhoidal disease is a common and troublesome condition. Excisional hemorrhoidectomy can assure the best chance of cure but it is hampered by postoperative pain and potential long-term morbidity therefore minimally invasive techniques have been developed. Since 2009 a doppler-guided hemorrhoidal dearterialization with laser (the hemorrhoidal laser procedure; HeLP) has been proposed to control symptoms without significant sequelae. The aim of this systematic review is to analyze the benefits and disadvantages of HeLP for symptomatic hemorrhoids. The Medline/PubMed, Embase, and Cochrane library databases were searched from January 2010 to March 2022, language was restricted to English and documents to the full text. Randomized and non-randomized, prospective and retrospective cohort studies were included. Risk of bias assessment was performed using the Risk of bias for non-randomized studies (ROBINS-I) and the RoB2 Tool for randomized clinical trial. Primary outcome was to assess the efficacy of HeLP on symptoms' resolution. Secondary objectives were postoperative pain and complications, comparison with other interventional techniques, and evaluation of long-term recurrence. Whenever possible, a meta-analysis was conducted. The GRADE approach was employed to assess the certainty of evidence. We included six non-randomized and one randomized study. HeLP improved or resolved preoperative symptoms in 83.6 to 100% of patients during follow-up. In the randomized study symptoms resolved in 90% of patients after HeLP and 53.3% after rubber band ligation as comparator. Published data indicate that HeLP is effective, relatively safe, with limited recurrence rate, after a short to medium follow-up. The quality of evidence was however low. There is a paucity of studies assessing the benefits or harms of laser dearterialization for the treatment of hemorrhoids and randomized trials are furthermore rare, therefore trials with adequate power and proper design, assessing the advantages and disadvantages of HeLP versus other minimally invasive techniques, are needed. Furthermore, studies evaluating long-term follow-up are wanted.

Minimally Invasive Treatment for Advanced Hemorrhoids.

Hemorrhoids, the most common anorectal disease, give rise to symptoms such as bleeding, prolapse, and pruritus. The treatment for advanced hemorrhoids (Grade III or IV) is gradually shifting toward minimally invasive procedures. These procedures focus on reduction of blood flow in hemorrhoids. Conventional hemorrhoidectomy (CH), also known as Milligan-Morgan or Ferguson hemorrhoidectomy, is considered as the standard treatment for Grade III and IV hemorrhoids because it achieves the lowest recurrence rate. Over the years, alternative minimally invasive techniques such as stapled hemorrhoidopexy and transanal hemorrhoidal dearterialization (THD) have been developed. A new, effective sclerosant, aluminum potassium sulfate and tannic acid (ALTA), has been developed in Japan and has been used for all grades of hemorrhoids; however, its effectiveness declines over time. Other minimally invasive, nonsurgical procedures, including rubber band ligation, endoscopic injection sclerotherapy, and infrared coagulation, have also been performed for Grade III hemorrhoids. Those minimally invasive treatments improve bleeding and prolapse and are highly recommended for patients who are unfit for CH. THD with mucopexy or ALTA sclerotherapy has also been performed for Grade IV hemorrhoids. However, the recurrence rate after ALTA sclerotherapy for Grade IV hemorrhoids was higher than that for Grade III lesions in our case study. In conclusion, minimally invasive treatments are a valid alternative for patients with advanced hemorrhoids after clear explanation of recurrence rates and possible complications.

Transanal hemorrhoidal dearterialization (THD) for hemorrhoidal disease: An Italian single-institution 5-year experience analysis and updated literature review.

Hemorrhoidal disease is a highly prevalent, chronic disorder that usually compromise patients' quality of life. Despite recent advances in pharmacologic and surgical therapeutic options, a clear treatment "gold standard" is lacking. Our aim is to analyze the outcomes following Transanal Hemorrhoidal Dearterialization (THD) procedure. Patients who failed conservative treatment and underwent THD Doppler between 2017 and 2021 were enrolled. Follow-up interviews (consisting of clinical examination, Visual Analog Scale for pain-VAS, Vaizey incontinence score, Hemorrhoid Severity Score) were administered 1 week, 2weeks, 1 month and 6 months after surgery. Forty-seven out of 75 patients were male, and the mean age was 50 (±17.9) years. Hemorrhoids were classified as Goligher's degree II in 25 cases, III in 40 and IV, simple irreducible without ischemic changes, in 10. The mean operative time was 35 (28-60) minutes, and most procedures were performed with epidural anesthesia (80%). No intraoperative complications occurred, and 73 patients (97.3%) were discharged within post-operative day 1. Early post-operative pain and bleeding occurred in 37.3% and 8% of patients, respectively. No patients experienced anal incontinence and severe symptoms at 6 months after surgery. The overall success rate was 97.3%. THD is safe and effective in hemorrhoidal disease at degree II if bleeding, III, and IV without ischemic changes, both as a first intervention and on recurrence. Physician and patient need to understand each other's expectations, weight the risks and benefits, and customize the treatment.

Experience of transanal hemorrhoidal dearterialization in the surgical treatment of grades II-IV hemorrhoids that bleeding

The aim of the work was to analyze the use of Transanal Hemorrhoidal Dearterialization (THD) in the surgical treatment of hemorrhoids of various degrees. The use of THD for complicated hemorrhoids in 514 patients for the period 2008–2021 was analyzed on the clinical basis of the Department of Surgery No.3 of the Bogomolets National Medical University (Ukraine). The average age of the patients was 39.1 years. 159 (30.9%) patients had grade II hemorrhoid, 299 (58.2%) – grade III, 56 (10.9%) – grade IV. All patients had manifestations of rectal bleeding and periodic prolapse of hemorrhoidal nodes, 75 (14.6%) patients had a pain syndrome associated with anal fissures, 19 (3.7%) patients underwent THD for recurrent (after performing other operations) hemorrhoids. No severe postoperative complications were observed. The average length of stay in the hospital was 1.3 days. The working capacity of the patients was restored after 3–5 days. Since 2015, THD has been performed according to the method updated by the authors, which was called Distal Doppler-controlled Dearterialization (DDD). We compared the results of performed THD before and after supplementing her DDD. When comparing THD before and after supplementing its DDD, a significant (p=0.00007) increase in the specific gravity of surgical interventions in stage III hemorrhoids while preserving the quality and duration of the postoperative course was revealed. Also, the number of THD in combination with surgery for chronic anal fissure, the number of operations for recurrent hemorrhoids increased significantly (p<0.05), which indicates the validity and effectiveness of the technique as an operation of choice in the surgical treatment of stage II–IV hemorrhoids. Application of the updated technique using DDD facilitates the performance of mucopexy, allows performing operations at later stages of complicated hemorrhoids. Keywords: proctology, THD, DDD, Doppler-controlled dearterialization.

Safety and Effectiveness of a New Electrical Detachable Microcoil for Embolization of Hemorrhoidal Disease, November 2020–December 2021: Results of a Prospective Study

Purpose: The purpose of this study was to prospectively evaluate the efficacy and safety of a new, bare platinum, detachable microcoil as a metallic embolization agent in the treatment of hemorrhoidal disease. Material and Methods: This prospective single-center study evaluated a new, bare platinum, electrical, detachable microcoil (Prestige plus coil (Balt Montmorency France)) for use in vascular embolization in patients with hemorrhoidal disease. Between January 2020 and January 2021, 24 embolization procedures were performed in 21 patients (12 males, 9 females; mean age 44.3 ± 7.3). The inclusion criteria were: (a) participants with grade I, II and III hemorrhoidal disease on the Goligher classification; (b) patients older than 18 years of age with a score of greater than 4 on the French bleeding score (FBS) scale; (c) patients with scores greater than 2 on the scale of discomfort proposed by Tradi and Farfallah. (d) patients who underwent treatment that included the use of the new novel coil (Prestige plus coil (Balt)) as an embolic material. The exclusion criteria were participants who failed to provide informed consent and participants diagnosed with rectal bleeding due to other causes (cancer, fissures or others). Participants with severe renal insufficiency, non-correctable coagulation abnormalities and adverse reactions to the contrast medium not correctable with medication were also excluded. The symptoms, technical aspects, the transarterial approach, clinical and technical success complications and short-term outcomes were assessed. Results: Technical success was obtained in 100% of the cases. Seventeen (80.9%) patients experienced improvements in their hemorrhoidal disease. The VAS and QL scores improved by 4 and 1.5 points (81.2% and 87.5%), respectively, after embolization (pV: 0001). Three (14.2%) patients underwent a second embolization due to rebleeding. One patient (4.7%) underwent surgery. No major complications were observed. Three patients had minor complications. The assessment of subjective post-treatment symptoms and QL surveys showed significant differences from the baseline survey. Likewise, the measurement of the degree of satisfaction using a telephone survey at 12 months revealed a high degree of patient satisfaction over 10 points (mean 8.3 ± 1.1). Conclusions: The present study demonstrates that the use of the new, platinum, detachable, electrical microcoil is safe and well-tolerated in the treatment of hemorrhoidal disease. Key points: Catheter-directed hemorrhoidal dearterialization (CDHD) is the procedure of embolization with embolic agents for the treatment of internal hemorrhoids. CDHD is a simple and safe procedure that is accepted by patients and preserves the anal sphincter; it presents few complications when metal devices or microspheres are used as embolic agents. As the recommended embolization agent in treatments, the Prestige electrical, detachable coil is a safe, easy-to-use and effective arterial embolic device.

Long-Term Results with Hemorroidectomy THD in Disease Hemorrhoidal

1.1. Objective: To analyze prospectively a series of 300 cases of hemorrhoidal disease managed with transanal hemorrhoidal dearterialization guided by Doppler ultrasound (THD) 1.2. Material and Methods: During the months of May 2011 to June 2019 a total of 300 patients were included with an average age of 43 years, (3%) were diagnosed with hemorrhoidal disease grade II, grade III (15%), grade IV (10%) and mixed hemorrhoidal disease (72%), predominantly male (57%), which were treated with THD; surgical time, intensity of postoperative pain, recurrence, recovery time and time of return to work were analyzed. 1.3. Results: The average age was 43 years, with a predominance of 57% male, the predominant symptoms before surgery were 100% bleeding, 79% prolapse and 60% pruritus, 3% had Grade II hemorrhoids, 15% grade III, 10% Grade IV and 72% mixed hemorrhoids, the average surgical time of the surgery was 15.9min (range 15-20 min), 1 day hospital stay (100%), 2.3% presented urinary retention, in The VAS scale at day 1 patients presented a value of 4 (range 2-7), at day 7 a value of 2 and at day 30 a value of 0 in all patients, the recovery time on average was 10 days and return to work in 14 days (range 10-20 days), recurrence of 3%, 10 patients It is presented evidence of new external flaps. 1.4. Conclusion: This study shows that patients treated with THD hemorrhoidectomy adequately manage the disease with low recurrence rate and less postoperative pain as well as complications.

Early postoperative outcomes of a novel nonexcisional technique using aluminum potassium sulfate and tannic acid sclerotherapy with mucopexy on patients with grade III hemorrhoids.

PurposeAluminum potassium sulfate and tannic acid (ALTA; Zion, Mitsubishi Pharma Corp.) is an effective sclerosing agent for internal hemorrhoids. ALTA therapy with a rectal mucopexy (AM) is a new approach for treating hemorrhoidal prolapse. This study compared the early postoperative outcomes of AM surgery with Doppler-guided transanal hemorrhoidal dearterialization and mucopexy (DM) in patients with third-degree hemorrhoids.MethodsAM surgery was performed on 32 patients with grade III hemorrhoids and was compared with a cohort of 22 patients who underwent DM surgery in a previous randomized controlled trial.ResultsThe pain scores during defecation were significantly lower in the AM patients beginning 4 days after surgery. The total use of analgesics 2 weeks postoperatively was significantly lower in the AM patients than in the DM patients (3.5 tablets [range 1.6–5.5] vs. 7.6 tablets [range 3.3–11.9], P=0.04). The length of operation, blood loss, and incidence of postoperative complications were significantly lower in the AM patients than in the DM patients. During 12 months follow-up, recurrence of prolapse occurred in 1 patient who underwent AM surgery.ConclusionAM surgery is effective, with lower complication rates and postoperative analgesic requirements, and is a less invasive treatment for patients with grade III hemorrhoids compared to DM surgery.

Transanal Hemorrhoidal Dearterialization (THD) Anolift-Prospective Assessment of Safety and Efficacy.

The adjunct of a mucopexy to conventional dearterialization has become a routine part of the transanal hemorrhoidal dearterialization procedure in order to facilitate the management of the prolapsing component and has helped to expand the indications of this technique to more advanced stages of hemorrhoidal disease. A simple technical modification of THD with targeted mucopexy (TM), called Anolift, is described. The aim of the study was to evaluate the safety and effectiveness of this technical variation. The procedure consisted of two parts: one aimed at the dearterialization and the other concentrated on the management of the prolapsing component. Once all the arteries were identified and transfixed an Anolift targeted mucopexy was performed using a continuous barbed suture with a synthetic absorbable monofilament (Polydioxanone) 2/0 Filbloc (Assut Europe) stitch mounted on a 4/8 30 mm needle. Severity of hemorrhoidal symptoms was scored from 0 to 20 using a dedicated questionnaire: the Hemorrhoidal Assessment Severity Score (HASS). From May 2018 to November 2020, 60 patients with hemorrhoidal disease (HD) underwent a THD Anolift procedure. Three patients experienced severe post-operative pain and 10 (23%) suffered with difficulty in evacuation. The median follow-up period was 15.5 months (range 2–32 months). The mean HASS changed from 16.43 pre-operatively to 1.95 post-operatively (p < 0.0001). Pre-operative HASS very strongly correlated with the degree of hemorrhoids (p < 0.001), while there was no correlation between the pre-operative HASS or the degree of hemorrhoids and the post-operative HASS (p = 0.163). There was no significant difference in predicted post-operative HASS according to the pre-operative HD stage. One patient (1.6%) with circumferential IV hemorrhoids had a recurrence and required a further THD. Two patients had excision of skin tags (3%). The Anolift technique is safe and effective for the management of HD even in patients with advanced stages.

Selective Hemorrhoidal Dearterialization with High Mucopexy in the Surgical Treatment of Hemorrhoidal Disease

AbstractThe doppler-guided transanal hemorrhoidal dearterialization technique associated with mucopexy is a noninvasive surgical option used to treat hemorrhoidal disease (HD). Objective To compare and analyze the results using a variation of the doppler-guided transanal hemorrhoidal dearterialization technique with the technique of selective hemorrhoidal dearterialization with high mucopexy in the treatment of HD. Method A total of 292 patients who underwent surgical treatment for grade II, III and IV HD from March 2012 to December 2017 were studied. From this total, 110 (37.6%) patients underwent a conventional doppler-guided transanal hemorrhoidal dearterialization with mucopexy (CD), and 182 (62.3%) underwent selective hemorrhoidal dearterialization with high mucopexy (SHeLF). In the group of patients undergoing CD, 4 patients (3.64%) had grade II HD, 82 (74.55%) grade III, and 24 (21.82%) grade IV. In the group submitted to SHeLF, 18 (9.89%) patients had grade II HD, 86 (47.25%) had grade III, and 65 (35.71%) had grade IV. The same surgeon operated all patients under spinal anesthesia. In patients undergoing CD, six arterial branches have been dearterialized, while in patients undergoing SHeLF, the hemorrhoidary nipples submitted to a dearterialization were selected (from 1 to 5) by intraoperative evaluation followed by high rectal mucopexy. In the postoperative period, the following parameters were evaluated: pain, tenesmus, bleeding, and recurrence.Moderate results to severe pain was a postoperative complaint reported by 13 (11.82%) patients undergoing CD, and by 19 (10.44%) undergoing SHeLF. Intense tenesmus was reported by 26 (23.64%) patients undergoing CD and by 7 (3.85%) undergoing SHeLF. Three patients (2.73%) undergoing CD and 1 (0.55%) undergoing SHeLF evolved with postoperative bleeding. One patient (0.55%) in the group undergoing CD required surgical review of hemostasis. Six patients (5.45%) who underwent CD and 8 (4.39%) who underwent SHeLF were reoperated due to disease recurrence. Conclusion Comparing statistics, patients undergoing the SHeLF technique have less postoperative pain, tenesmus and postoperative bleeding when compared with CD.

Evolution of Surgical Management of Hemorrhoidal Disease: An Historical Overview.

Hemorrhoidal disease (HD) is the symptomatic enlargement and/or distal displacement of the normal hemorrhoidal cushions and is one of the most frequent diseases in colorectal surgery. Several surgical or office-based therapies are currently available, with the aim of being a more tailored approach. This article aimed to elucidate the historical evolution of surgical therapy for HD from ancient times, highlighting the crucial steps, controversies, and pioneers in the field. In contrast with the previous literature on the topic that is often updated to the 1990s, with the introduction of stapled hemorrhoidopexy and transanal hemorrhoidal dearterialization, this article describes all new surgical and office-based treatments introduced in the first 20 years of the 2000s.

An update on surgical treatment of hemorrhoidal disease: a systematic review and meta-analysis.

Pathologic hemorrhoids are common among adults age 45-65. Hemorrhoids are characterized as internal or external, and grades 1-4 based on severity. The type and grade dictate treatment, with surgical treatment reserved for grades 3/4. The aim of this study is to compare clinical outcomes of various surgical treatments. A systematic review was conducted to identify randomized clinical trials that compare surgical treatments for grade 3/4 hemorrhoids. A Bayesian network meta-analysis was done using NetMetaXL and WinBUGS. A total of 26 studies with 3137 participants and 14 surgical treatments for grade 3/4 hemorrhoids were included. Pain was less in patients with techniques such as laser (OR 0.34, CI 0.01-6.51), infrared photocoagulation (OR 0.38, CI 0.02-5.61), and stapling (OR 0.48, CI 0.19-1.25), compared to open and closed hemorrhoidectomies. There was less recurrence with Starion (OR 0.01, CI 0.00-0.46) and harmonic scalpel (OR 0.00, CI 0.00-0.49), compared to infrared photocoagulation and transanal hemorrhoidal dearterialization. Fewer postoperative clinical complications were seen with infrared photocoagulation (OR 0.04, CI 0.00-2.54) and LigaSure (OR 0.16, CI 0.03-0.79), compared to suture ligation and open hemorrhoidectomy. With Doppler-guided (OR 0.26, CI 0.05-1.51) and stapled (OR 0.36, CI 0.15-0.84) techniques, patients return to work earlier when compared to open hemorrhoidectomy and laser. There are multiple favorable techniques without a clear "gold standard" based on current literature. Open discussion should be had between patients and physicians to guide individualized care.